Use Payor Allowed Amounts to Increase Collections

Increase collections from insurance companies by viewing this free 30 minute webinar. See how to use Payor Allowed Amounts to check if you have been paid on-time and in full for your services by the insurance companies. This built-in feature of our Genesis Chiropractic Software shows what you’re supposed to be paid for various CPT codes that you bill out. Use this to actually see what you were paid and then you can see if it’s an underpayment or not. Insurance companies are known to underpay by “mistake” as they try to keep money that should be paid to your Chiropractic practice. If an underpayment is detected then the claim can be sent to your billing team for follow-up with that insurance company. Let them get to the bottom of it for you. Watch the webinar immediately right on this page.

Jason: Welcome to those who are just joining, we are going to start in just a moment here. Waiting just for a few more people to jump from the web section to the audio section and then we’ll get today’s webinar started. Thanks for joining us. You’ll notice that you’re all muted and we ask that you check your questions in so that we can answer them as the webinar goes on. We’re going to start, we’re going to spend about 10 to 15 minutes on our topic today which is Collections, very specific to Collections, the Payer Allowed feature in our system, and we’ll talk about why it’s important and then we’ll open this up to any type of question that you might have after that. So, I’m looking forward and we’ll give you…actually it’s 2:05 now, Jessica. Let’s get started. So, my name is Jason Barnes, chief operations officer here and this is starting to sound like a broken record, isn’t it?

Jessica: A little bit.

Jason: As always. Jessica Pancost [SP], the head of our training and help desk team here at our organization, is co-hosting. So, today we are talking about a topic near and dear to pretty much every practice owner that we have and then a whole bunch of staff who are directly impacted by collections. And so, today we’re talking about collections, so we’re going to spend a little bit of the time talking, not necessarily about why collections are important, I think that one’s self-explanatory unless you want to spend some time on that Jess?

Jessica: No.

Jason: You’re good? but we want to talk about how to measure collections. Want to talk about how to break it down in two separate areas where a practice owner can make sure A, all their visits are getting paid, and B, all the visits are getting paid the right amount.

Today, we’re going to primarily focus on the second of the two problems we discussed. The first problem of making sure all visits are getting paid, it’s not necessarily a simple problem to solve. However, we will spend just a moment in a broad stroke on how we approach that, and it has to do with our dashboard. You can see here that I’ve blown up one of the most important parts of our home screen and it’s the dashboard, here of course, in our dummy practice where we’re going to look at collections month to date, total outstanding accounts receivable, meaning all of the charges that need to be followed up on from an insurance perspective, and then we break down those accounts receivable into three separate buckets.

The accounts receivable will be on 30 days, beyond 60 days and beyond 120 days. So, in this particular case, there are $32,419 total outstanding accounts receivable, $26,000, $6,000 and then zero dollars beyond 120 Days. We break this into percentages so that folks can measure, not only compared to themselves, but to the industry, how well they’re doing at making sure all visits are getting paid.

Good question, Jess. “How do I know if my accounts receivable is really low and all our visits are getting paid?” It basically translates into if you have a visit that’s not paid, that’s sitting out there past 120 days, the likelihood of collecting on it, I don’t care if it’s from a patient or an insurance company, goes down significantly. Your goal as a practice owner should be to monitor this number. This zero dollars is unheard of, but it happens, and we can start talking about ways that it happens in this webinar series, but this is a great indication that you’re getting all of your visits paid.

If your accounts receivable over 120 days is very, very low, one, two percent, it means that you’re getting 98%, 99% of your visits paid. And the rest of them are either getting written off, appropriately we hope, but there’s ways of tracking that as well or they’re being moved into a paid status which is the ultimate goal.

So, if you know that your visits are getting paid, and again that’s not where we’re going to be spending the bulk of our time today, the other one is, “Are your visits getting paid the right amount?” And I ask a bunch of interrogative questions today want to go over the answers to them. What is the right amount? Jess, how does, you’re talking to somebody about collections, do you have any idea, you know, to tell them if they’re getting paid the right amount for their CPT codes?

Jessica: No.

Jason: Why not?

Jessica: I don’t know [inaudible 00:04:37], but different contracts and different states and everyone gets paid…

Jason: Its complicated, it’s a complicated answer and the first thing we want to let all of our providers know is if it doesn’t seem simple for you, that’s correct, you’re not in a simple industry. What I need to establish before we start looking into this is it’s meant to be confusing, it’s meant to not have a straightforward answer, and we’re going to talk about “in” and “out of” network providers today. So, we want you to know that insurance companies make this challenging to find out how much you should be getting paid, on purpose.

Your fee schedule is like the holy grail, not meant to be found. It’s hard to know what your reimbursement rates are supposed to be, so we’ve provided you some tools to help break that out. So, I’m actually going to get into some of the results first before we show the feature, and these are real world examples of providers in Illinois. We have over 35 providers in Illinois and out of those I broke down some comparisons today of individual providers and what they’re getting paid on certain CPT codes.

So, today we’re actually going to delve into an example of one provider saying, “I have a colleague that practices 75 miles away from me and this colleague gets paid more.” The first thing we have to do is learn to compare apples to apples. When somebody gets paid more, you can’t just compare, “He’s making $50,000 a month and I’m taking $30,000 a month.” We have to figure out a way to compare units to units. We have to figure out how to compare a CPT code that’s in-network for Blue Cross Blue Shield to CPT code that’s in-network for Blue Cross Blue Shield, and if we try and do it any other way, we find ourselves frustrated in drawing a conclusion that we can actually work off of.

So, today we’re going to look at a collections analysis of two separate practices. One practice is billing out a CPT code, we’ll call this a manual therapy code right here and we’ll focus in on this and I’ll make it a little bit bigger as we scroll across. Blue Cross Blue Shield 97012. They’re billing out $18 per unit, excuse me, yeah, $18 per unit, and they had in their history which is, this is a six months’ history that we’re looking at, $13.09 is their minimum allowed amount and $18 is their maximum allowed amount.

If you look at the average, the average allowed amount that this practice is getting is $17.96, so it’s very, very close to the maximum allowed amount. We compared both providers within this same state and we found that both providers were getting exactly the same allowed amounts. Their difference was nonexistent across all of their CPT codes, each one was getting the same allowed amount. In this particular case, the provider was relieved, but Jess, does that answer the question if they’re getting paid the same amount if they have the same allowed amounts?

Jessica: Not at all.

Jason: Jess, I thought we were making progress. I don’t mean to patronize Jess or anyone else on this call. Just because you have the allowed amount means you now at least identified the amount that you should collect between both the patient as well the insurance company. What steps do you take after that is what we’re going to dive into next. The allowed amount is essential. If you have a lower allowed amount Jess, what are some of the possible ramifications as far as collections are concerned, if you have the wrong allowed amount?

Jessica: You’re going to paid less, so your collections are going to be lower.

Jason: What is an allowed amount, exactly? Where does this allowed amount, where does it come from? Why is it there?

Jessica: It comes from the insurance company, and it’s saying that this is the amount that you are allowed to collect for this particular service.

Jason: Got it. So, you’re not allowed to collect any more? Why not? I’m very valuable at what I do, rhetorical question. You can be in or out of network and accept allowed amounts. Lots of providers feel that being in network breaks down walls and gains them better access to their patients. Some feel that being out of network is a way to allow that number to be higher and not having allowed amounts so that they can collect more money for their services.

This webinar and the direction you’re getting right now, in no way, shape or form, is meant to give you guidance on whether or not you should be in or out of network. But if you find yourself in that situation, you have to compare apples to apples. I have to compare column J to column K and make sure that both allowed amounts are for the same payer, either in or out of network. I have to know whether or not, as a provider, I’m getting paid the right amount per visit. I can’t do a comparison to someone who’s in-network to someone who’s out of network, because if they’re not accepting an allowed amount, you’re not going to get an accurate comparison.

If you’re in network, 99.9% of the time you have a contracted amount and you know what you should be getting paid, and today we’re going to talk about how our systems helps you make these comparisons as well as takes you to the next level, to detect when those are being underpaid. Because, together with both the insurance company and the patient, every single time, you should be getting paid $34.82 per unit of this CPT code so that you can report back to insurance companies, to your boss, to your patients, that everything is accurate on their statement and that they’ll be able to reconcile the differences at the end of their care.

So, we know that these…and all these allowed amounts, all this information was pulled out of our system. This is a straight representation of a report and we want to make sure that anybody who sees this knows that they can gain access to this information in our system.

So, we’re moving to our demo account and we’ve come about half way through this particular topic. To recap where we’re at right now, you know that you’re getting paid all of your visits if you have a low accounts receivable over 120 days. For getting paid the right amount, the first step is making sure that you know what your allowed amount is per visit. The second step is how are you going to make sure you detect if that allowed amount is lower? What scenarios, Jess, have you found will cause the allowed amounts to be posted at a lower rate than what they should be?

Jessica: The allowed amount that we got from insurance was lower for, you know, they process it wrong.

Jason: Arbitrarily? Just arbitrarily, they’re just posting it lower?

Jessica: Well, yes.

Jason: It happens, right?

Jessica: Yes.

Jason: It happens, arbitrarily and this is not a conspiracy theory call, I don’t know if there’s somebody in an ivory tower at, you know, Aetna that is making arbitrary reductions in payments. However, they are, let’s just say, going to reject a CPT code that’s covered, when, let’s just say, you did a verification of benefits, you know it’s covered, but they’re saying it’s a non-coverage service. It comes in as an ERA posted electronically in the system as a non-covered service. You know it’s a covered service.

How are you going to detect when something is either reduced or not paid at all? Our answer to this is automation every single time. There’s no way you can trust an employee to go look at this, and so we want to show everybody the first step here in solving the problem of getting underpaid on visits and it’s called Payer Allowed Amounts.

All right, it’s coming up here. So, in this particular report and configuration we’re able to see three things. We’re able to see a clinician, a CPT code, and then the data that goes along with that CPT code, how it’s billed out, and what amounts are allowed for that. In this situation in our demonstration accounts, we don’t necessarily have a lot of data for this one. So that’s why we pulled up our spreadsheet to show you what the results look like. And these results are exactly indicative of what our reports in the system show because it’s real provider information. We didn’t want to see this with any information that could be sensitive to an individual practice.

So, here you’re going to see that CPT code, you’re going to see the clinician, you’re gonna see the Blue Cross Blue Shield and this will allow you to, over a period of time, three months, two months, whatever period of time you look at, to see what your minimum allowed and maximum allowed amounts are. The big difference, ladies and gentlemen, is here we are able to actually enter an allowed amount. If you have a contract with Blue Cross Blue Shield for a CPT code, that you should get paid $200 for it and you get $196, but you see that CPT code 10,000 times in a year, you’re going to miss $40,000 of reimbursement.

That’s how insurance companies in our experience have really dealt a blow to the health-care industry, not necessarily by denying claims, but by underpaying them hoping that you don’t have the means to A, track it, and then B, to do anything about it. So, the people who are under our stewardship, Jess and I, we coach them to, especially for their in-network contracted CPT codes, to actually enter in these allowed amounts. So, just what happens if somebody enters in this allowed amount for this line item, for this particular CPT code of 97150 which we’re billing out at $35 per unit and ends up…needs to get paid $20.83 per unit, and it comes in at $20.

Jessica: As long as they have those numbers and that report, when that claim gets filled out, if it receives a lower allowed amount, than what is entered on that report the claim gets rejected with a message saying that it was underpaid and to reach out to their insurance and find out why it was underpaid. Why was…the allowed amount was low.

Jason: First thing is it identifies it, right. We’re going to identify what it is but it’s not just identified. Lots of times it’s easy to identify claims that were underpaid. You can run a report and figure out which claims were underpaid too, right? But then what? How do you identify those claims, assign them to somebody and then follow up? It takes it a step further, ladies and gentlemen, by including a full workflow process that will reject the claim, put it on a work bench stating that it’s underpaid and that we need to call the insurance company and figure out why they have the audacity to undervalue the services provided by one of our doctors. So, we take it a step further.

So, in this particular case, we are looking at the allowed amount only. If the allowed amount comes back with a separate amount, that still can leave you slightly underpaid. Here, the insurance might have an allowed amount there of the correct amount but might actually not give you a full understanding of what the patient responsibility versus the insurance responsibility is. So, that takes some additional manual coordination. At that point, if the insurance company didn’t pay their full amount, there’s going to be a balance left on the claim, and that EOB or that electronic remittance advice that will electronically post in the system is gonna say that the patient owes, and any way you look at it, Jess, we’re not going to lose that claim. That balance has to be dealt with by the provider or by our billing team, one way or another.

The whole point is, you cannot allow yourself to be in a situation to manually find these and then manually figure out how you’re going to follow up on each one of them. I’ve seen nothing but misery and missed claims in that situation and the provider who is in question, who we decided to use as the case study here hadn’t talked to us in a number of years. Came back and was really, really concerned that his colleagues were telling him that he was getting paid so much less than them.

And we got their colleagues written permission to do this comparison, and after the comparison, it turns out not only were there allowed amounts exactly 100% percent identical for all of the ones so that we could compare apples to apples, but, Jess, we took it a step further and if you work with your coach and… Oops, I clicked on the wrong one, and you… No, I did not click on the wrong one.

All right, if you look at the actual payments that are expected, we have an algorithm that we run that actually does the analysis of your payments, and we actually looked at those payments between those two, the one who had this feature turned on had been being getting paid more. Even though they weren’t working with it, they weren’t putting the time in and tweaking the system to work out better, they just turned on the setting for Payer Allowed Amounts and it turned out that it allowed them to get paid more than their colleague, located in their state but in not a noncompetitive market.

So, if you would like to get this type of information where you see exactly what your insurance expectation should be, we’re able to run this on a request by request basis, ask your coach and we’ll be able to put a session together where we go over payer by payer, what your expectations for insurance reimbursement should be and if you’re short on any. So, in this particular situation we were able to point out that his colleague was missing out on some reimbursements in a number of different areas where he had absolutely no money not coming in. He was getting paid 100% of the Blue Cross Blue Shield visits on the allowed amounts.

The colleague who had the same allowed amounts had deficits all over the place, and that will bring me to the last point I want to make about collections. Collections are not just a function of having a great billing service or good technology, they are the function of teamwork. The difference between these two offices is one responds to requests from the billing team and the other doesn’t.

Great team work has yielded excellent results for this practice owner who woke up in a cold sweat one morning thinking that he was losing thousands of dollars, found out that he wasn’t losing anything and was able to alert his colleague that he should get to the claims on his workbench because doing those resulted as in 100% over 2015 anyway, of his allowed amounts being paid on Blue Cross Blue Shield of Illinois claims.

This particular story has a happy ending but many, many providers who end up speaking to us end up realizing that they are losing money because they’re being underpaid. Our policy is to enter in these allowed amounts and whenever we get the contracts from our providers, you must be involved for us to do this, or to turn on a setting to automatically set allowed amounts according to some expectations that we arrived at via an algorithm, and we’re happy to do that as well.

So, this really concludes the portion where we’re talking about collections. I’ll recap one last time, there’s two ways of measuring collections, one, are all your visits getting paid? And number two, are all your visits getting paid the right amounts? What we focused on today is that allowed amount is the first step to making sure that you’re not underpaid, the second step is actually clearing your work bench and the claims that need to be worked on. If you do that, we’ll make sure that we know what patient balances are accurate, what insurance balances need to be paid, and we’ll fight with the insurance companies on your behalf to make sure that they don’t underpay you.

And I’ll thank you for your time on that and if there’re any questions, we’ll open up right now. Please let us know and we’ll do our best to answer them. So, open that up right now and, you know, in a minute or two, if we don’t get any other questions on this, we’ll open up to pretty much any question but you can put that question in the chat at any moment, and we’ll tackle it in just a minute or two.

The providers in question, Jess, are part of a very large coaching network, and after our call today, they said, “Well, why doesn’t everybody know about this?” And I said, “Well, show up to our webinar today, you know, get on and ask some good questions and we’ll see what we can do about getting the message out to the entire network.” He was feeling a sense of pride, actually he and she, both of the practice owners, were feeling a sense of pride that were doing so well, even though they hadn’t been manning the helm at this particular juncture. It was a good call.

All right, no questions about the collections, we would absolutely love of any other questions about anything else system related or process related, and we’d be happy to help you. All right, if there are no questions, I’d like to thank everyone for showing up today and best of luck with all your patients.

Jessica: Wait, wait. Jamie, we’re still here, if you want to keep typing, I know you can’t see our screen but…

Jason: I’m sorry was that little premature there?

Jessica: Yeah, I got it, there’s a “Wait” typed in. What would cause an insurance company to not pay the allowed amount?

Jason: I’ll tackle this one. Well, there is no good reason to. Every now and then they just make errors, there’s a spectrum Jamie. We get all sorts of excuses of to just…like, what excuses do they use. Errors for sure but we work with a number of compliance officers, one of which that we recommend, actually works for actually his own company, Custom Chiro Solutions and he was employed, and I’m sharing an anecdote that he shared so I’ll give him credit for it. He actually worked for Blue Cross Blue Shield for a little while. And he described to us how their adjustors, the people who actually adjudicate claims, were paid. They had to hit a certain accuracy rate, so out of a hundred claims, they had to hit 85% accuracy.

So, he said what they would do is they would do 90 claims perfectly, then they would just reject the last 10 claims for whatever reason they could come up with because it didn’t affect their bonus. Now, the numbers that I’m quoting you might be off a little bit as far as the percentage of accuracy, but in this particular case the premise is, they didn’t care about that last percentage because they’re a federally regulated industry and they had met the burden, not only to get paid but to keep their status as a payer.

So, we find all sorts of times where it’s hard to get the verification of benefits. When you do get the benefits verified they’re not 100% accurate, you have to fight with them and that can change your allowed amounts, because you’re not going to get the money from a patient sometimes especially if you told them, no your benefits cover this, and then you find out that there’s still deductibles left or that the excess ends up being the patient’s. You know, if their visits are up, and it ends up being, “I just can’t go back to my patient and charge him $400 more than what we originally agreed upon, even though the information we’d gotten at the time of services being rendered seemed as accurate as possible.”

And again, I’m only talking on a few instances, there are a lot of other reasons why allowed amounts can be different. There are different plans for Aetna Blue Cross Blue Shield. I didn’t mention United Health Care to be very, very specific, I did not mention United Health Care because I want to get to them in a second. Within those different plans, even though your contract is, there are different contract amounts, but you’re not able to differentiate between one plan and another.

It’s really quite challenging. So the reason I didn’t mention the United Health Care is United Health Care and Aetna, more occasions that I see now, they don’t pay for CPT code, they pay per visit. They’re going to pay you $55 or $35 dollars, whatever the amount is, for the visit and that’s it.

So, how do you allocate that over the CPT codes which are never consistent in that visit? That actually changes allowed amounts and that’s even if you’re in-network, Jamie. So there are a lot of twists and turns to tracking collections that need to take place. The first step again is you have to identify them, the second step is you have to have policies to actually work on them. So, as these are rejected and sent back to the workbench, we have to be able to interpret the ERA or the EOP, make the appropriate move based on our experience as well as what information we’re getting there with the insurance company.

Yes. I see, I go out and network with UHC because of that stuff, we get it. But at the same time, Jamie, across this great land United Health Care is becoming the small business insurance company of choice, right? United Health Care, Oxford if you’re on the east coast and so they are getting away with a lot of underpayments as a result of this. And there are other ways of tackling that as well. I mean, you can’t get a patient to come in on Monday and Tuesday, but you can bill out different, separate line items for separate visits, for office codes and then adjustments. So, if you’re a current client of ours, make sure you get our billing SWOT team involved to go over those types of things with you because there are ways of making sure that they don’t get to pull that on every single visit that you have.

Oh, Jamie’s not a client. Jamie, head over to any one of our websites, genesischiropracticsoftware.com and click on it and it allows you to schedule right there, you’ll see our availability. I doubt you’ll see a great deal of availability for this week but next week we should start opening back up again.

All right. Any other questions? Oh, thank you Jamie, we really appreciate it. I’ll just give them one more minute because I don’t want to commit the sin that I did a minute ago. All right, I think we can call it at this point. That’s all, Jess.

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